Simulation Design Template
Date: 8/31 File
Name:
Adolescent AsthmaDiscipline:
NursingStudent Level: Students in Pediatric Nursing course/Basic
Expected Simulation Run Time:
15-20 minutesGuided Reflection Time:
30 minutesLocation: Simulation Lab
Location for Reflection: Debriefing room, near Sim Lab
Admission Date: August 31
Today’s Date: August 31
Brief Description of Client
Name: Julio MoralesGender: Male
Age: 14 Race: Hispanic
Weight: 63.5 kg Height: 167cm Religion: Catholic
Major Support: mother Phone: 777-0009
Allergies: No known drug allergies Immunizations: Current per CDC recommendations
Attending Physician/Team: Pediatrician, Dr. Marla Goodrich
Past Medical History: No pertinent medical or surgical history. Patient diagnosed with asthma at age 4 years. Emergency Department visits X 2 in past 2 years for exacerbation of asthma. Has multiple environmental allergies including grass, mold, and animal dander. Uses albuterol metered dose inhaler PRN.
History of Present Illness: Mild wheezing began last night. Increasing distress noted during the night, mother brought patient to Emergency Department this morning due to no reported response to inhaler Social History: Lives with mother, father,
grandmother, and 4 younger siblings. Is in 8th grade at local middle school.
Primary Medical Diagnosis: Exacerbation of asthma
Surgeries/Procedures & Dates: None
Psychomotor Skills Required Prior to
Simulation
Exacerbation of asthma Basic respiratory assessment Use of pulse oximeter
Oxygen administration
Communication skills/developmentally appropriate Use of metered dose inhaler
Cognitive Activities Required prior to
Simulation [i.e. independent reading (R),
video review (V), computer simulations (CS), lecture (L)]Attendance at lecture: Pediatric Respiratory Illness (L)
Oxygen Lab
Read Chapter on Asthma (R) Medication review: Inhaler Pharmacology review: Albuterol
Simulation Learning Objectives
1. Perform focused respiratory assessment 2. Identify signs of respiratory distress3. Implement non-pharmacologic methods to aid breathing, i.e. positioning 4. Review physician orders
5. Administer oxygen PRN 6. Administer albuterol safely
7. Evaluate effectiveness of interventions
Fidelity (choose all that apply to this simulation)
Setting/Environment
ER Med-Surg Peds ICU OR / PACU Women’s Center Behavioral Health Home Health Pre-Hospital OtherSimulator Manikin/s Needed: SimMan as 14
year old boyProps:
baseball cap, hospital gown with gym shorts underneathEquipment attached to manikin:
IV tubing with primary line fluids running at mL/hr
Secondary IV line running at mL/hr
IV pump
Foley catheter cc output PCA pump running
IVPB with running at mL/hr
O2
Monitor attached
ID band Morales, Julio, include DOB Other
Equipment available in room
Bedpan/Urinal Foley kitStraight Catheter Kit Incentive Spirometer Fluids IV start kit IV tubing IVPB Tubing IV Pump Feeding Pump Pressure Bag
O2 delivery device (type) nasal canula and simple mask
Crash cart with airway devices and emergency medications Defibrillator/Pacer
Medications and Fluids
IV Fluids:Oral Meds
: IVPB:IV Push
:IM or SC:
Diagnostics Available
Labs X-rays (Images) 12-Lead EKG OtherDocumentation Forms
Physician Orders Admit Orders Flow sheetMedication Administration Record Kardex
Graphic Record Shift Assessment Triage Forms Code Record
Anesthesia / PACU Record Standing (Protocol) Orders Transfer Orders
Other
Recommended Mode for Simulation
(i.e. manual, programmed, etc.)
Suction
Other Albuterol MDI
Roles / Guidelines for Roles
Primary Nurse Secondary Nurse Clinical Instructor
Family Member #1 Patient’s mother is in room with patient
Family Member #2 Observer/s
Recorder
Physician / Advanced Practice Nurse Respiratory Therapy Anesthesia Pharmacy Lab Imaging Social Services Clergy
Unlicensed Assistive Personnel Code Team
Other
Important Information Related to Roles
Patient is upset about being in the hospital; he is missing a basketball game in school today. His mother is worried, upset with son about not using his inhaler often enough
Significant Lab Values
Physician Orders
Admit to peds observation unit VS q 1 hour
Continuous pulse oximetry
Administer oxygen to maintain SpO2 > 95% Albuterol MDI (90 micrograms/inhalation), 2 puffs Q 15 minutes X 2
Labs – CBC and Basic metabolic panel Chest x-ray - AP and lateral
Student Information Needed Prior to
Scenario:
Has been oriented to simulator
Understands guidelines /expectations for scenario
Has accomplished all pre-simulation requirements
All participants understand their assigned roles
Has been given time frame expectations Other
Report Students Will Receive Before
Simulation
Julio was just admitted to the Observation Unit, needs an assessment. His mother says he was wheezing a little last evening, during the night he began wheezing more and coughing, could not sleep. She said he has an inhaler but she does not know if and when he uses that. He reportedly tried during the night but distress continued. Lab and x-ray have not been here yet. Dr. Goodrich just wrote the orders.
References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used For
This Scenario:
(site source, author, year, and page)Asthma is a chronic inflammatory disorder of the airway with obstruction that can be partially or completely reversed, and increased airway responsiveness to stimuli.
In asthma, the inflammation causes the normal protective mechanisms of the lungs (mucus formation, mucosal swelling, and airway muscle contraction) to react excessively in response to a stimulus, (a “trigger.”) Airway narrowing results from airway swelling and production of copious amounts of mucus. Mucus clogs small airways, trapping air below the plugs, causes muscle spasm that can become uncontrolled in the large airways.
Diagnosis of asthma has 4 key elements: symptoms of episodic airflow obstruction; partial reversibility of bronchospasm with bronchodilator treatment, exclusion of alternate diagnosis, and confirmation by spirometry of measurement of peak expiratory flow variability.
Bronchodilators (i.e. albuterol) relax smooth muscle in airways, results in bronchodilation within 5-10 minutes, has some side effects such as tachycardia, nervousness, nausea, and vomiting
OUTCOMES: Patient will evidence stable vital signs and be afebrile, exhibit unlabored respirations and patent airway, tolerate full diet, tolerate age-appropriate activity with evidence of respiratory distress, weakness, or exhaustion, have moist mucus membranes, verbalize understanding and demonstrate cooperation with respiratory therapy
Supplemental oxygen may be required, humidified preferred, best administered by face mask or nasal canula. Place patient in sitting or upright position to promote ease of breathing.
Discharge planning: child and family need a thorough understanding of asthma, how to prevent attacks and how to treat to avoid unnecessary hospitalization.
Reference
London, M.L., Ladewig, P.W., Ball, J.W., & Bindler, R.C. (2003). The Child with Alterations in Respiratory Function (pp.1035-1046), Maternal-Newborn & Child Nursing, Family-Centered Care. Upper Saddle River, NJ: Prentice Hall.
2007 NCLEX-RN Test Plan Categories and Subcategories
Choose all areas included in the simulationSafe and Effective Care Environment
Management of Care
Advance Directives Establishing Priorities
Advocacy Ethical Practice
Case Management Informed Consent
Client Rights Information Technology
Collaboration with Interdisciplinary Team Legal Rights and Responsibilities Concepts of Management Performance Improvement (QI) Confidentiality / Information Security Referrals
Consultation Resource Management
Continuity of Care Staff Education
Delegation Supervision
Safety and Infection Control
Accident Prevention Medical and Surgical Asepsis Disaster Planning Reporting of Incident/Event Emergency Response Plan Irregular Occurrence/Variance Ergonomic Response Plan Security Plan
Error Prevention Standard /Transmission-Based / Handling Hazardous and Infectious Materials Other Precautions
Home Safety Use of Restraints/Safety Devices
Injury Prevention Safe Use of Equipment
Health Promotion and Maintenance
Aging Process Health Promotion Programs
Ante/Intra/Postpartum and Newborn Care Health Screening Developmental Stages and Transitions High Risk Behaviors
Disease Prevention Human Sexuality
Expected Body Image Changes Immunizations
Family Planning Lifestyle Choices
Family Systems Principles of Teaching/Learning
Growth and Development Self-Care
Health and Wellness Techniques of Physical Assessment
Psychosocial Integrity
Abuse/Neglect Psychopathology
Behavioral Interventions Religious and Spiritual Influences Chemical and Other Dependencies on Health
Coping Mechanisms Sensory/Perceptual Alterations Crisis Intervention Situational Role Changes
Cultural Diversity Stress Management
End of Life Care Support Systems
Family Dynamics Therapeutic Communications
Grief and Loss Therapeutic Environment
Physiologic Integrity
Basic Care and Comfort
Assistive Devices Nutrition and Oral Hydration Complementary and Alternative Therapies Palliative/Comfort Care
Elimination Personal Hygiene
Mobility/Immobility Rest and Sleep
Non-Pharmacological Comfort Interventions
Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications Parenteral/Intravenous Therapies Blood and Blood Products Pharmacological Agents/Actions Central Venous Access Devices Pharmacological Interactions Dosage Calculation Pharmacological Pain Management Expected Effects/Outcomes Total Parenteral Nutrition
Medication Administration
Reduction of Risk Potential
Diagnostic Tests Potential for Complications from
Lab Values Surgical Procedures and Health
Monitoring Conscious Sedation Alterations Potential for Alterations in Body Systems System Specific Assessments Potential for Complications of Diagnostic Therapeutic Procedures Tests/Treatments/Procedures Vital Signs
Physiologic Adaptation
Alterations in Body Systems Medical Emergencies Fluid and Electrolyte Imbalances Pathophysiology
Hemodynamics Radiation Therapy
Illness Management Unexpected Response to Therapies Infectious Diseases
Scenario Progression Outline
Timing
(approximate)
Manikin Actions
Expected Interventions May Use the
Following Cues
First 5 minutes Patient is flat in bedTemp: 37.2 BP: 110/68 P: 90 reg RR: 22 SpO2: 91% Wheezing bilaterally Normal heart and bowel sounds
Use of faculty,staff or student as patient voice: “I hate coming to the hospital. I have a game today.”
Wash hands
Introductions, address patient and his mother
Elevate HOB
Perform assessment, focus on respiratory with bilateral
auscultation and pulse oximetry as priorities.
Teamwork, primary and secondary nurse work together to assess and perform
interventions
Role member providing cue: Patient’s mother Cue: “Why does he keep having this breathing trouble? We have been here for this same thing before.”
Next 10 minutes Wheezing persists RR ^ to 24 SpO2: 89%
“I hate this, it’s hard to catch my breath”
“I used the stupid puffer.”
Review physician orders Administer oxygen via nasal canula at 2 L/min
Administer albuterol via metered dose inhaler, utilizing 5 rights of med administration, assessing patient’s knowledge, and giving age appropriate instructions
Role member providing cue: Patient (sounds short of breath with talking) Cue: “I had that inhaler a long time. Since I was in 7th grade last year. I always have to use it when I’m running, and when I’m outside, and if the cat comes in the house” Final 5 minutes Slight improvement in
wheezing after albuterol and oxygen
RR to 18 HR to 108 SpO2: 95
“How come my heart is pounding. I hate this.”
Continuous assessment of respiratory status
Assess inhaler knowledge and use. When and how often is inhaler used? How long has patient had inhaler? Does he know how to check whether it is empty?
Begin teaching of inhaler and side effects
Role member providing cue: Patient
Cue: “What do I have to do so my mom won’t bring me back here again? I’m old enough to take care of myself.”
Debriefing / Guided Reflection Questions for This Simulation
(Remember to identify important concepts or curricular threads that are specific to your program) 1. How did you feel taking care of Julio and his mom?
2. What were your priorities for this patient?
3. How did the team determine who would do what? How did you communicate?
4. What do you know about individualizing Julio’s care based on his age? (developmentally appropriate)
5. What did you do well? Were your interventions effective?
6. To Observers: What questions or comments do you have for the team?
7. What will this family need to know prior to discharge? How can you help them manage Julio’s asthma?
8. What do you want to know more about after caring for Julio? 9. What is the most important thing you learned from this case?
Complexity – Simple to Complex
Suggestions for Changing the Complexity of This Scenario to Adapt to Different
Levels of Learners
• Julio could have disability such as developmental delay or other chronic illness
• Patient could be in school nurse, pediatrician or nurse practitioner office
•
Patient could be unresponsive to q 15” treatments, could require consult with physicianDownloaded from http://sirc.nln.org with permission of the National League for Nursing and Laerdal Medical Corporation. Duplication of this document is prohibited without permission. To request permission, please email us at: [email protected]
